Thursday, September 23, 2010

For over 3 years, candidate and President Obama promised the American people that under his health care reform, people could keep their doctors if they so chose. He didn't say "most" people, he didn't say "some" people, he said "everyone" would be able to keep the doctor of their choice. A few months before he signed the new law, he admitted that this part of reform was somehow left out. Oops, I guess in all the back room deals and closed meetings for over a year with Senator Reid and Speaker Pelosi, they must have somehow misunderstood the President's promise. The President must be really mad now. He gave direct orders to the Pelosi/Reid team to draft a law that allowed one of his most important promises to the American people and apparently they simply didn't listen. In my office, an intentional mistake of this proportion would most certainly lead to a few people losing their jobs. (Maybe that will be the case on November 2nd for Nancy Pelosi and Harry Reid.)

I "wear a few hats" in my career. I am a member of a private practice group. My group has been serving patients from Kaiser Permanente in Georgia for 20 years. These patients constitute about 15% of our general neurology practice. I am also employed by a multiple sclerosis center, a separate non-profit organization. Multiple sclerosis (MS) is a chronic, potentially disabling condition of the brain and spinal cord. About 50% of patients if left untreated, or if partially treated, will develop progressive symptoms within 10 years. We have effective medications to slow the disease. Most patients also have many other symptoms that need continual management or they will have severe impact on their lives. Because it is such a complex chronic medical illness, there are about 150 neurologists nationally that treat the majority of patients with multiple sclerosis.

Due to health care reform, Kaiser has decided to "internalize" neurology (meaning they are hiring their own neurologists to take care of patients with neurological diseases). I have a great deal of respect for Kaiser in Georgia. Their hospital doctors are among the best I have worked with and the philosophy of their healthcare model is one of the best in the world. However, in the outpatient setting their problem is the frequent migration of physicians. Over the years, this has been the case with their neurologists. Many have come and gone, which has lead many patients to be unhappy with their care. The Kaiser patients have always rated their experience with our group extremely high. I will never tell you that we are smarter than other doctors, but I promise you that our work ethic and energy is second to none. Patients greatly appreciate our efficiency and care. As of November 1st, 2010, none of that history or patient satisfaction matters. It doesn't matter that many of them have severe, disabling conditions that I have been managing for 10 years. The relationship we established, the life threatening experiences I have shared with them, the many emotional family meetings we have had together, do not matter as "they do not get to choose their doctor if they want."

This is a story you will hear a million times over once Obamacare is implemented. Patients will have no choice whatsoever about who will take care of them, no matter how complex their disease. The White House health care team has explicitly told physicians that they will be working as employees for "health homes." These health homes (called ACO's or accountable care organizations) will be owned predominantly by hospitals. Patients will have to assign themselves to an ACO or one will be appointed for them depending on their location. It won't matter if you have a chronic, highly specialized condition and the best physician may be employed in another ACO. You will have no choice. All of your care will be dictated by the first line medical professional at the ACO like (to quote the White House team), "a nurse practitioner, physician assistant, care coordinator, or dietician." It is likely that your doctors in the ACO will move to other jobs on a frequent basis, just like in the Kaiser system. Why? Because they will be employees, not business owners, and they will have nothing tying them down to an ACO like they do to their privately owned practice.

The ACO idea is not a bad one and was not invented by President Obama or the politicians. In essence, like in Kaiser, groups of physicians of all specialties would work together to provide the best care at the most affordable price. This would greatly reduce costs by reducing over utilization of services, would open communication between physicians, and limit unnecessary tests. I don't know a single physician who would not promote such a system. Why has this idea not blossomed already? Because of the Government and the obstacles they have placed to prohibit coordinated care for the last 30 years. That's right, the Government that is now asking us to trust them in fixing the problems has been the major obstacle and source of escalating health care costs for years. Do you trust them? How's that "get to keep your doctor" working out for you so far?

Even Kaiser realizes that a restrictive ACO model will not work for them. They are allowing patients with multiple sclerosis to continue to come to our MS Center. They realize that our Center is focused on an expensive and disabling disease in a manner that cannot be replicated internally. (I suspect it might also have something to do with the fact that we take care of many of their employees and family members who have MS.) Kaiser plans to allow a general neurology appointment with my group if the time to see a Kaiser neurologist is too long or if we have more expertise in the condition. This is not likely to happen under Obamacare if it follows the path of many socialized medical systems, like Great Britain. In Obamacare, our MS center will have to fold under an ACO run by a hospital which will represent only a fraction of patients in Georgia. Patients from outside our system will not get the care they need and some will likely become disabled sooner. (We have patients, by the way, that understand the importance of care at our Center who come from almost all 50 States.)

Nancy Pelosi and Harry Reid could have delivered the President's promise and still allowed an ACO idea to flourish. The Government could have removed many of the anti-trust laws, allowed medical systems to coordinate care, and set up standards for care and cost. Standards have been developed already by most physician organizations. These standards focus on tests, medications, and care. There is no reason why physician organizations could not have been required to develop standards across the board. Under this system, coordinated efforts between doctors and hospitals would have competed with one another to improve outcome and reduce costs. Different models would have been developed and we could have learned from the better ones. Patients would have had the power to choose their ACO based on need, expertise, and cost. Many private ACO's would have been able to develop relationships with specialty centers, like our MS Center, as it would be far more costs effective than trying to duplicate such a service.

Why did this not happen? Because, the politicians who drafted Obamacare did not want "different models." Different models would have meant choices for the people. Different, private, and independent models would have meant the private market would have prevailed and the Government takeover of the industry would not have been possible. Government takeover of patient's choices, health care dollars, and lives would not have been possible. The reform of the system would have been so easy with just a few simple laws if they really wanted to improve the system and reduce costs. Do you think the "get to keep your doctor" error was the only one?

The opinions expressed by Dr. English are his own and do not reflect the opinions of any affiliated institutions.

Dr. Jeffrey B. English is a Board Certified Neurologist with sub-specialty training in Clinical Neurophysiology. He is in private practice in Atlanta, Georgia. Dr. English is the Clinical Research Director at the Multiple Sclerosis Center of Atlanta, a non-profit organization for the treatment of patients with multiple sclerosis. He helped develop and helps run the Center. He is also a national speaker on multiple sclerosis and on the economics of health care delivery. Author Dr. Jeffrey English writes the HC On Call series exclusively for Basil & Spice. Visit his Writer's Page.